Please note: this is an online agreement and so please do not print this out, please just fill it out online (you can type using the keyboard) and then click Submit at the end. If you have any questions, call us at 212-614-8057.
Thank you!
Christian M Steiner
E/ P / L / PDF

    The Undersigned (as herein defined below) wishes to enter into this Service Agreement (the “Agreement”) with Home Care Associates, Inc., (d/b/a an independently owned and operated Home Instead Senior Care franchise) (“Provider” or "Agency" used interchangeably) to provide Client (as herein defined below) with non-medical homecare service. Each Home Instead Senior Care(R) franchised business is independently owned and operated.
  • / /
  • Please specify the relationship of this person to the Senior
  • A Home Health Aide cannot pre-pour medications, they can only remind them to take them from the pill organizers. Please call us if this is not clear at 212-614-8057
  • Questions? call us at 212-614-8057
  • * We reserve the right to freeze up to one week's worth of services.
  • Please add
    1. Insurance Carrier Name
    2. Phone and fax # of the Insurance carrier
    3. Policy and Claims #s

Home Instead Senior Care
400 East 56th Street
Professional Wing, Suite #2
New York, NY 10022
P: 212-614-8057
F: 212-614-8056 




 Manhattan's Trusted Source of Homecare to the Elderly